Medication Administration for CNAs Two (2.0) contact hours Expiration Date: 12/4/2017 First Published: 12/4/2013 Reproduction and distribution of these materials is prohibited without RN.com content licensing agreement. Copyright 2013 by RN.com. All Rights Reserved. Acknowledgements RN.com wishes to acknowledge the valuable contributions of.nadine Salmon, MSN, BSN, IBCLC is the Clinical Content Manager for RN.com. She is a South African trained Registered Nurse, Midwife and International Board Certified Lactation Consultant. Nadine obtained an MSN at Grand Canyon University, with an emphasis on Nursing Leadership. Her clinical background is in Labor & Delivery and Postpartum nursing, and she has also worked in Medical Surgical Nursing and Home Health. Nadine has work experience in three countries, including the United States, the United Kingdom and South Africa. She worked for the international nurse division of American Mobile Healthcare, prior to joining the Education Team at RN.com. Nadine is a nurse planner for RN.com and is responsible for all clinical aspects of course development. She updates course content to current standards, and develops new course materials for RN.com. Conflict of Interest RN.com strives to present content in a fair and unbiased manner at all times, and has a full and fair disclosure policy that requires course faculty to declare any real or apparent commercial affiliation related to the content of this presentation. Note: Conflict of Interest is defined by ANCC as a situation in which an individual has an opportunity to affect educational content about products or services of a commercial interest with which he/she has a financial relationship. The author of this course does not have any conflict of interest to declare. The planners of the educational activity have no conflicts of interest to disclose. There is no commercial support being used for this course.
Purpose & Objectives The purpose of this course is to enable the Certified Nursing Assistant (CNA) to safely assist patients in administering medications. Principles of medication safety will be reviewed. After successful completion of this course, you will be able to: 1. Discuss the principles of safe medication administration (including the 6 Rights of Medication Administration). 2. Describe the medication administration procedure and importance of documentation. 3. Review medication considerations in the elderly, allergies and drug interactions. 4. Discuss medication safety and the National Patient Safety Goals (NPSGs) relating to medication safety. 5. Define medication errors, High-Alert Drugs, Look Alike / Sound Alike drugs and adverse drug events. Glossary Adverse Drug Event Any event in which the use of a medication, a device, or a special nutritional product (for example, infant formula) may have caused harm to a patient. Adverse Event An injury caused by medical personnel. Allergies A bad immune response by the body to a substance to which it is hypersensitive. High-Alert Drugs High-alert medications are drugs that have a high risk of causing patient harm if used in error. Look Alike/Sound Alike Drugs Some medications can look or sound like other drug names, which may lead to potentially harmful medication errors. Medical Error The failure of a planned action to be completed as intended. National Patient Safety Goals (NPSGs) Are goals for the safe administration of medication, to decrease medication errors. These goals were developed by The Joint Commission (TJC) to help accredited organizations address specific areas of concern in regards to patient safety. Near Miss An incident or error that hospital personnel caused, but did not result in an injury to the patient this time. Sentinel Event An unexpected event that caused death or serious injury to a patient.
Introduction The CNA s essential responsibilities can be divided into 3 C s, namely the provision of Care, Comfort, and Communication. The CNA is an important part of the healthcare team, and provides a valuable service by performing routine patient care, providing for the comfort of the patient and communicating with the RN according to set policies and procedures. Ensuring the comfort of the patient is a large part of the CNA s scope of practice. Assisting patients with their administration of medications helps to improve the comfort and general well-being of the patient. The responsibilities of a CNA vary greatly from state to state. Always be familiar with the scope of practice in your own state. Registered nurses may delegate medication administration tasks to CNA s in certain states, if the CNA s training and competence to perform the task have been well established. It is your responsibility to inform the supervising RN of your particular skills and training, so that you can perform tasks that are within your legally protected scopes of practice. A CNA who possesses the proper education, training and experience may in fact administer certain medications to patients, under the supervision of the delegating nurse. Communicating patient needs and procedures completed is also a critical part of the CNA s job responsibility. Timely and accurate reporting is a key element in avoiding errors in patient treatment. The CNA must be skillful in accurate and thorough observation, documentation and reporting. More Info The CNA s scope of practice refers to the tasks within his or her certified skill set. It is important to know one s scope of practice as defined by your state and your facility. Scope of Practice The administration of specific medications can be delegated to a CNA if the CNA has received training in medication administration, is competent to administer certain medications and has adequate supervision by an RN. Drugs that may be appropriate for a CNA to administer may include: 1. Oral, topical, suppository, eye drops, ear drops 2. Single dose immunizations administered intramuscularly in the deltoid muscle; and 3. Intradermal injections for allergy testing (Department of Veterans Affairs [DVA], 2013). Drugs that are not appropriate for administration by a CNA include: 1. Any controlled substance 2. Experimental drugs 3. Medications requiring dosage adjustments or calculation of dosages 4. Medications requiring specialized training 5. Intravenous (IV) Administration, IV Drips (infusions) or IV Push drugs, unless the CNA is certified in IV therapy
6. High Alert Medications 7. Administration of medications to patients who are deemed medically unstable Check with your facility and Nursing Board to see if your scope of practice allows you to administer the medications listed. Test Yourself A CNA can administer cancer drugs (chemotherapy). A. True B. False- Correct! Rational: Chemotherapeutic drugs usually require dosage calculations. An RN is required to administer chemotherapy. Additional Training and Certification Numerous states now allow CNAs to be specially trained and pass medications. In light of the licensed nursing shortage, many states are adopting special programs to train certified nursing assistants or CNAs to perform sophisticated medical duties and take on highly complex responsibilities in patient care. Although not all states have stepped-up and designed extended training for higher achieving CNAs, many are currently enacting legislation and are expecting their board of nursing to comply with state-approved programs and certification examinations. CNA specialists enjoy higher salaries and more diverse duties and interesting assignments. See below for states that allow CNAs to administer certain medications, after the completion of additional training and certification in medication administration: Arizona Arkansas California Colorado Connecticut Florida Georgia Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Minnesota Missouri Montana Nebraska New Hampshire New Jersey New Mexico New York North Carolina North Dakota Oregon South Carolina South Dakota
Texas Virginia West Virginia Wisconsin (FindCNAClasses.com, 2013) Medication Administration Assisting your patient to take medications safely is an important task that requires critical thinking, good observation skills and excellent documentation. At all times, the safety and wellbeing of the patient is of the greatest importance. You are responsible for a patient s safety and must never administer a drug that you do not know what the side effects and possible drug interactions are. Some states do not allow nursing assistants to administer nebulizers or injections. The RN is responsible for delegating correctly, but if you ever feel concerned about your ability to perform a medication administration task for any reason or need more information, it is your responsibility to let the RN know. If you are ever uncomfortable with administering a particular drug, share your concern with the RN. If you are still uncomfortable after talking to your RN, talk to another supervisor. Please note! Do not feel pressure to complete a task that has been delegated to you if you think it is beyond your scope of practice! Principles of Medication Administration There are 6 important principles to follow when administering medication that all healthcare professionals should follow carefully. Always remember the following 6 Rights of medication administration to safely dispense medication to your patient. The 6 rights of medication administration are listed below. Click each link below to see the description: 1. Right Drug: Drugs can be referred to by their generic or brand name, which can be very confusing. Always compare the order for the drug on the Medication Administration Record (MAR) with the actual label of the drug, and the order on the Physician s Order Form. If the two do not match exactly, call the RN for further assistance. Some medications have names that look and sound similar to other meds but are very different, and can cause fatal outcomes if given by mistake. 2. Right Dosage: Dosage is the strength of the medication and the amount to be given. Compare the dosage prescribed on the MAR with the Physician s order and the pharmacy label. The two should match exactly. If not, contact the RN. 3. Right Time: The drug must be given as close to the time it is ordered to be given as possible. Medications should not be given more than 30 minutes before the scheduled time or 30 minutes after the scheduled time. Some drugs have special instructions such as give before or after meals, or at bedtime. PRN medications are only to be given when needed.
4. Right Route: The oral route is the medication route most commonly used, but there can be other routes of administration. Be sure you are trained to administer drugs by any other route. If you are unsure of the procedure for administering a drug, always talk to your RN. Remember that if your patient is nauseated, oral medication may not be effective if the patient vomits after administration. 5. Right Patient: Always double-check your patient s identity by checking the patient s name and patient ID number on the wrist-band, verbally confirming the identity of the patient (when possible), and comparing the patient name and ID number to the medication order/mar. Never use the patient s room number as a method of confirming a patient s identity as room numbers can change. 6. Right Documentation: After you have administered the medication, it is very important to write / record it in the MAR, and sign the MAR at the bottom. Always be sure that you are documenting for the right patient. You will also need to document the medication administration in the patient s chart. The patient s medical record is a legal document, and according to a court of law, if something is not documented, then it is assumed that it was not done. The Medication Administration Procedure Before beginning the process of preparing a medication for your patient, wash your hands according to your facility s Policy & Procedures. On entering the patient s room, announce yourself and the reason for your visit. Checking the patient s vital signs is good practice before administering medications. If the patient s heart rate (pulse), blood pressure or respiratory rate is different to their baseline values, discuss your findings with the nurse before administering any medication. Before preparing any medication, check the order on the Physician s Order Form, and check the patient s medical record for any allergies before administering any medication. Discuss the medication with the patient and inform them of the type of medication you will be giving to them, and the reason for the medication. Never leave medication at the bedside. Did You Know? Question any order that you think may be incorrect. As a healthcare professional, you are responsible for your own actions. Preparing the Medication Do not prepare the medications until the patient is ready to accept it. Only dispense medications that are stored in clearly marked containers. Do not use liquid medication that is cloudy or medications that have changed from the original color. Always check the expiry date and administer the medication as prescribed. If the medication is dropped, follow your facility s guidelines for disposal and documentation. Document the medication administration immediately on completion of the task, before starting another task. Observe the patient regularly after the administration of the medication to observe for any side effects such as increased sleepiness, elevated heart rate or respiratory rate. If you observe any changes in
the patient s condition, notify the nurse immediately and document your findings. Did You Know? Medications should not be crushed or mixed with food or juice unless specified on the MAR. Crushing a medicine can change the way the medication is released and absorbed by the patient and can result in an accidental overdose. Medications that are taken with juice may also interact with the juice and cause an adverse reaction. If you are unsure about whether a medication can be crushed or mixed with food, ask your nurse for advice. Documentation Tips Documentation is a very important responsibility of all healthcare professionals. It is a legal requirement and it also provides information to other healthcare providers to ensure patient safety. Note the following tips for accurate and complete documentation: 1. Always document immediately after administering a medication. If you perform another task before documenting, you take the risk of documenting incorrectly and this can place the patient s safety at risk. Never document that a medication has been given before it is actually given. 2. Record the patient s full name, the date and time of giving the medication, the medication name, dosage (amount), route of administration and your full name and title. 3. Always write neatly, and do not erase an error or use white-out. Simply place a line through the incorrect entry. 4. Make sure each entry is dated and signed. 5. If a patient refuses a medication, it must be documented in the patient s notes and reported to the nurse immediately. 6. Always document a reason for administering a medication that is PRN (as needed), so that the reason for administering the medication is clear. For example, if a stool softener is ordered PRN, you would make a note in the documentation that the stool softener was administered because the patient was complaining about straining during bowel movements. Observing Side Effects and Adverse Reactions It is important for the CNA to carefully observe the patient after administering medication, and to report any unusual observations to the nurse. The most common medication side effects of oral medications are nausea and vomiting. Some side effects can be bothersome but others can be life-threatening, such as swelling of the throat and abnormal heart rhythms. A decrease in urine output can be an important side effect that should be reported to the nurse immediately. Observe the patient closely after giving a medication to see if any reaction to the medication occurs. Any changes in the patient s condition must be communicated in a timely manner. Communication can be in the form of written documentation, or it can be verbal communication. More Info Most medications have side effects, but people can react differently to the same drug at any given time.
Please note! Ringing in the ears (tinnitus) could be a sign of aspirin toxicity. Medication Considerations in the Older Patient Older patients (seniors) are at greater risk for drug toxicity than younger patients, for several reasons: 1. The elderly generally have several chronic illnesses that require medication, and are at greater risk for these medications to interact with each other to produce unwanted side effects. 2. The elderly have a slower metabolism, and a decreased ability to metabolize (process) drugs. Age-related changes in the liver, kidneys, central nervous system, and heart make elderly people more vulnerable to medication overdose and side effects. 3. Additional medication challenges in the elderly include short-term memory impairment which may cause a person to take incorrect dosages, multiple doses, or even skip doses. Impaired vision may also lead to over-or under-dosage. Medication Interactions Some medications can interact badly with other medications, causing harm to a patient. Some medicines can also interact badly with some foods, causing unwanted side-effects. For example, theophylline is a medication that is used to treat asthma and other lung disorders. This drug contains xanthines, which are also found in tea, coffee and chocolate. Consuming large amounts of these substances while taking theophylline can increases the risk of drug toxicity (overdose). Certain vitamins and minerals can impact medications too. Large amounts of green leafy vegetables (such as spinach and broccoli) that are high in vitamin K can counteract the effects of drugs given to prevent blood clotting, such as heparin and warfarin. Dietary fiber also affects drug absorption. Pectin and other soluble fibers slow down the absorption of acetaminophen, a popular painkiller. Bran and other insoluble fibers have a similar effect on digoxin, a major heart medication. Allergies A rash or a life threatening reaction can occur at anytime with any medication. An allergy is a bad immune response by the body to a substance to which it is hypersensitive. A severe form of allergy is called anaphylaxis, and can occur when a patient is exposed to a substance to which he or she is allergic to. This type of allergic reaction calls for emergency management. Some signs of an allergic reaction may include: Itching / hives Swelling of the throat / difficulty breathing (dyspnea)
Decreased blood pressure and / or an irregular heart beat (tachycardia) Nausea and / or vomiting Loss of consciousness If your patient experiences any of these symptoms, call the nurse immediately. Did You know? Allergic reactions can occur at any time. An allergic reaction can occur to a particular medication, even when that same medication has been given to the same patient previously, without any bad side-effects. Common Medication Abbreviations The most common abbreviations are: Ad lib: Freely Q.D.: Every day (daily) Q.O.D.: Every other day Q.H.S.: Every night or at bedtime B.I.D.: Twice a day T.I.D.: Three times a day Q.I.D.: Four times a day P.R.N.: When necessary P.O.: By mouth SL: Sublingual (under the tongue) Ung: Ointment To avoid making a mistake, always ask the nurse for clarification if you are unsure of an abbreviation. If the medication label and the MAR are not the same on any of the 6 Rights of Medication Administration, ask your nurse to check the order with you. Medication Storage All medications must be stored safely, and according to the manufacturer s recommendations. If the medication requires refrigeration, do not forget to put the medicine back in the refrigerator after each use. Never store medicine near heat or a window. Some medications need to be protected from light, and others must be stored at room temperature. If medications are out of date, do not throw the medicine away without checking with your nurse first. Most medications must be locked away at all times. Medication Errors A medication error occurs when the wrong drug or dosage of a drug is given in error to a patient. Medication errors that cause harm are called adverse drug events. According to the Institute of Medicine, 7,000 people per year die from medication errors.
The Joint Commission (TJC) has implemented monitoring criteria to assure hospitals are monitoring and practicing safe medication administration. Potential adverse drug events are called near misses. In these situations, a medication related event had the potential to cause harm to a patient but did not result in an injury. Both categories of adverse drug events are concerning to healthcare professionals. Test Yourself Potential adverse drug events are called. Answer: Near misses Medication Safety & National Patient Safety Goals (NPSGs) The National Patient Safety Goals (NPSGs) were originally established in 2002 by The Joint Commission (TJC). TJC uses these NPSGs to help accredited organizations address specific areas of concern in regards to patient safety. These NPSG are updated periodically. The updated 2013 National Patient Safety Goals require all healthcare organizations improve the effectiveness of communication among caregivers (NPSG 2). The third NPSG addresses medication safety. All medications and medication containers and other solutions must be correctly labeled in a timely manner and patient medication information must be maintained and communicated accurately to all healthcare professionals (NPSG 3). This NPSG also requires us to use at least two patient identifiers (such as the patient s name and ID number) before administering any medication to a patient. Sound Alike, Look Alike Drugs Some medications can look or sound like other drug names, which may lead to potentially harmful medication errors. In 2001, TJC published a Sentinel Event Alert on look-alike and sound-alike drug names. This NPSG recognizes that healthcare practitioners need to be aware of the role drug names play in medication safety as well as system changes that can be made to prevent errors. Research has shown that breakdowns in communication are the most common cause of medication errors. Cause of Medication Errors The most common causes of medication errors are: Poor communication between healthcare providers. Poor communication between providers and their patients. Sound-alike medication names and medical abbreviations. Illegible prescriptions or confusing directions.
Communication is key to preventing medication errors. Why Does a Medication Error Occur? Medication errors can occur when the: Wrong medication is given to a patient. Wrong patient receives a medication prescribed for someone else. Incorrect dosage of a prescribed medication is given. Medication is given at the wrong time or not given at all. Wrong route of administration is used. Medication that is prescribed for a patient is not available. Wrong form of a medication is given, for example a liquid is given instead of a capsule. The medication error should also be documented immediately, in the patient s notes, according to your facility s policy. When a medication error occurs, you must notify the RN immediately. High-Alert Medications High-alert medications are drugs that have a high risk of causing patient harm if used in error. The Institute for Safe Medication Practices (ISMP) has created a list of high-alert medications to help alert healthcare providers recognize the dangers of administering these medications. CNA s should never be required to administer a high-alert medication. More Info: High-alert medications include anticoagulants (blood thinners), insulin, sedatives and narcotics. Conclusion Medication errors are preventable, and knowledge is your best defense against making a medication error. Before administering a medication, make sure you review the 6 Rights of Medication Administration and verify the identity of your patient correctly. Always follow your state and facility guidelines with regard to the types of medications you are allowed to administer. If unsure, check with your RN or supervisor. Remember that patient safety is your top priority and medication errors can often be avoided by open communication, diligence in preparing and administering medications and accurate and timely documentation. References Department of Veterans Affairs [DVA], (2013). The Use of Unlicensed Assistive Personnel (UAP) in Administering Medications. Retrieved Oct 31, 2013 from: http://www.va.gov/vhapublications/viewpublication.asp?pub_id=2872
FindCNAClasses.com (2013). States that allow CNAs to administer medications. Retrieved November 11, 2013 from: http://www.findcnaclasses.com/states-allow-cnas-administer-medications/ Institute for Healthcare Improvement [IHI], (2013). The Five Rights of Medication Administration. Retrieved November 11, 2013 from: http://www.ihi.org/knowledge/pages/improvementstories/fiverightsofmedicationadministration.aspx Institute for Safe Medication Practices [ISMP], (2013). ISMP High-Alert Medications. Retrieved Nov 11, 2013 from: http://www.ismp.org/tools/highalertmedicationlists.asp Disclaimer This publication is intended solely for the educational use of healthcare professionals taking this course, for credit, from RN.com, in accordance with RN.com terms of use. It is designed to assist healthcare professionals, including nurses, in addressing many issues associated with healthcare. The guidance provided in this publication is general in nature, and is not designed to address any specific situation. As always, in assessing and responding to specific patient care situations, healthcare professionals must use their judgment, as well as follow the policies of their organization and any applicable law. This publication in no way absolves facilities of their responsibility for the appropriate orientation of healthcare professionals. Healthcare organizations using this publication as a part of their own orientation processes should review the contents of this publication to ensure accuracy and compliance before using this publication. Healthcare providers, hospitals and facilities that use this publication agree to defend and indemnify, and shall hold RN.com, including its parent(s), subsidiaries, affiliates, officers/directors, and employees from liability resulting from the use of this publication. The contents of this publication may not be reproduced without written permission from RN.com. Participants are advised that the accredited status of RN.com does not imply endorsement by the provider or ANCC of any products/therapeutics mentioned in this course. The information in the course is for educational purposes only. There is no off label usage of drugs or products discussed in this course. You may find that both generic and trade names are used in courses produced by RN.com. The use of trade names does not indicate any preference of one trade named agent or company over another. Trade names are provided to enhance recognition of agents described in the course. Note: All dosages given are for adults unless otherwise stated. The information on medications contained in this course is not meant to be prescriptive or all-encompassing. You are encouraged to consult with physicians and pharmacists about all medication issues for your patients.